Building Blocks for Action - World Health Organization

1 G l o b a l r e p o r tNoncommunicable Diseases and Mental HealthWorld Health OrganizationBuilding Blocks for ActionInnovativeCare forChronic ConditionsCHAPTER 2 WHO Library Cataloging-in-Publication DataInnovative care for chronic conditions: Building Blocks for Action : global report1. Chronic disease 2. Delivery of Health care, Integrated 3. Long-term care 4. Public policy 5. Consumer participation 6. Intersectoral cooperation 7. Evidence-based medicine I. World Health Organization . Health Care for Chronic Conditions 92 4 159 017 3 (NLM classification: WT 31)This publication is a reprint of material originally distributed as WHO/MNC/ World Health Organization 2002 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization , 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: Requests for permission to repro-duce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.))

2 Dotted lines on maps represent approximate border lines for which there may not yet be full mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its report was produced under the direction of JoAnne Epping-Jordan, Health Care for Chronic Conditions. It is the first key component of a three-pronged WHO strategy to improve the pre-vention and management of chronic conditions in Health care systems.

3 This strategy is over-seen by Rafael Bengoa, Director, Management of Noncommunicable Diseases, and Derek Yach, Executive Director, Noncommunicable Diseases and Mental Health . The three WHO Health Care for Chronic Conditions projects related to this strategy are: Innovative Care for Chronic Conditions (managed by JoAnne Epping-Jordan) Improving Adherence (managed by Eduardo Sabat ) Primary Health Care for Chronic Conditions (managed by Rania Kawar)Technical input for this report was provided by the overall WHO chronic conditions team, as well as by a range of other WHO staff members. Administrative support was provided by Elmira Ade-nova, Health Care for Chronic Conditions. Writing team: Sheri Pruitt (principal writer); Steve Annandale, JoAnne Epping-Jordan, Jes s M. Fern ndez D az, Mahmud Khan, Adnan Kisa, Joshua Klapow, Roberto Nu o Solinis, Srinath Reddy, and Ed Wagner (supporting writers).

4 Case Example Contributors: Shitaye Alemu, Fu Hua, David Green, Desiree Narvaez, Jean Penny, Masoud Pezeshkian, Prema Ramachandran, Pat Rutherford, and Judith SefiwaICCC Framework Meeting Design and Facilitation: Peter KeyGraphic Design, first edition: Laurence HeadGraphic Design, this edition: Health and Development Networks WHO is exceedingly grateful to the many policy-makers, Health care leaders, and other experts who gave their time to provide comments and suggestions on this report at different stages. The production of this report was made possible through the generous financial support of the gov-ernments of Finland, Netherlands, Norway, and Chronic Conditions: The Health Care Challenge of the 21st Century28292. Current Systems Are Not Designed for Chronic ProblemsCurrent Systems Are Not Designed for Chronic ProblemsHealth care system has been defined as that system which encompasses all the activities whose primary purpose is to promote, restore, or maintain Health ( World Health Report 2000).

5 Thus, systems are remarkably expansive and include patients and their families, Health care workers and caregivers within organizations and in the com-munity, and the Health policy environment in which all Health related activities Brief History of Health Care Systems Historically, acute problems, such as certain infectious diseases, were the principal concern for Health care systems. Advances in biomedical science and public Health measures over the past century have limited the impact of many communicable dis-eases in most developed countries. And, while some infectious diseases continue to be a threat and an important consideration for Health care systems in many developing countries, these systems now must respond to an additional set of Health problems. Because current Health care systems developed in response to acute problems and the urgent needs of patients, they are designed to address pressing concerns.

6 For example, test-ing, diagnosing, relieving symptoms, and expecting cure are hallmarks of contemporary Health care. Moreover, these functions fit the needs of patients experiencing acute and episodic Health problems. However, a notable disparity occurs when applying the acute care template to patients who have chronic problems. Health care for chronic conditions inherently is different from Health care for acute problems, and in this regard, current Health care systems worldwide fall remarkably short. Health care systems have not kept pace with the decline in acute Health problems and the increase in chronic conditions. 1. Chronic Conditions: The Health Care Challenge of the 21st Century30312. Current Systems Are Not Designed for Chronic Problems In fact, Health care systems have not noticeably evolved beyond the conceptual approach used in diagnosing and treating acute conditions.

7 The acute care paradigm is pervasive and now permeates the thinking of decision-makers, Health care workers, administrators, and patients. The acute care model drives the Organization of care throughout the World even today, even in the most economically developed countries. To address the rising rates of chronic conditions, an evolution in Health care systems is imper-ative, and they have to advance beyond the acute care model. Acute care will always be neces-sary (even chronic conditions have acute episodes), but at the same time Health care systems must embrace the concept of caring for long-term Health problems. Patients, Health care organ-izations, and decision-makers have to recognize the need to expand systems to include new con-cepts. Decision-makers are instrumental in facilitating a shift in thinking about Health care.

8 What are the Current Problems? Micro-, Meso-, and Macro-LevelsOne strategy to organize thinking about Health care systems is to divide these complicated networks into strata or levels. Micro-, meso-, and macro-levels provide a reasonable framework and refer to the patient interaction level, the Health care Organization and community level, and the policy level, respectively. Each of these levels interacts with and dynamically influ-ences the other two. For example, consider the levels as linked by interactive feedback loops in which events at one level influence actions and events at another level, and so on. In this scheme, patients respond to the system in which they receive care, and Health care organiza-tions and communities are responsive to policies that in turn influence patients. And, the feed-back loops perpetuate.

9 When Health problems are chronic, the acute care practice model doesn t work. 1. Chronic Conditions: The Health Care Challenge of the 21st Century30312. Current Systems Are Not Designed for Chronic ProblemsWhen micro-, meso- and macro-levels work effectively within themselves, and successfully function in relation to each other, Health care is efficient and effective; patients experience better Health . Dysfunction within and among the levels creates waste and ineffectiveness. Unfortunately, concerning Health care for chronic conditions, dysfunction in the Health care system is between micro-, meso-, and macro- levels is not always clear. For example, when Health care personnel are not prepared to manage chronic conditions because of train-ing deficiencies, the problem could be considered a micro-level problem because it affects patients.

10 Training deficiencies could be considered a meso-level problem because it is the responsibility of the Health care Organization to ensure providers have the expertise and tools to care for patients. Alternatively, training could be considered a macro-level issue because a policy decision could alter medical training curricula or continuing education requirements to meet population demands. Micro-Level: Patient Interaction ProblemsWithin the micro-level of Health care, problems are evident. Systems fail to recognize the extraordinary importance of patients behaviours and the value of quality interactions with Health care workers in influencing the outcomes of Health care. There is ample scientific evi-dence regarding efficacious strategies for the micro-level ( , interventions for changing patient behaviours, techniques for increasing medication adherence, or methods for improving Health care worker communication); however, this evidence is not integrated into daily clinical prac-tice.